An Alternative to Surgery and a Colostomy Bag?
“Patients value quality of life more than a lot of doctors tend to give them credit for,” observes Christopher Anker, MD, a radiation oncologist at the University of Vermont Medical Center.
Dr. Anker’s philosophy – giving cancer patients a variety of viable treatment options, and empowering them to choose the approach that fits best with their lifestyle – recently took another step forward with a new clinical trial. This study, which builds on the positive outcomes of earlier research, now gives patients with cancer the opportunity to shorten their course of radiation treatment from six weeks to just five days, while also avoiding surgery.
For 48-year-old Patrick Austin of Montpelier, that approach made a world of difference in his treatment for colorectal cancer.
Something was wrong
“One day in September, about a year and a half ago, I came home from work feeling a little ‘rumbly in the tummy,’” Patrick recalls. “I had diarrhea, and then I saw a toilet bowl full of blood.”
That was his first clue that something was wrong. Dr. Anker notes that bleeding – along with a change in bowel habits – is a common first sign of colorectal cancer, and nothing to ignore. “Unfortunately, many people think the bleeding is due to a hemorrhoid, and they sometimes dismiss it. Patrick appropriately saw his primary care provider. He was right on top of it.”
Patrick had a colonoscopy within a week, then followed up with MRI and CT scans to verify the diagnosis: a cancerous tumor in the wall of the rectum. Fortunately, it was detected relatively early, and while it had grown all the way through the intestinal wall, it had not spread to lymph nodes or other organs. Nevertheless, the traditional treatment recommendation included surgery, which most likely would leave him with a permanent colostomy bag.
For Patrick, a ten-year veteran of the Sugarbush ski patrol and an active family man with a wife and two children – Arin, 18, a college freshman, and Ioan, a freshman in high school – “colostomy bag” was nearly as devastating to hear as “cancer.”
“I was vehemently opposed to surgery. I told the doctors, we’re going to try everything else, but that is off the table,” he says.
A new, non-operative treatment through a clinical trial
Patrick’s Austin’s oncologist at UVM Health Network - Central Vermont Medical Center mentioned a new clinical trial that involved a non-operative course of treatment and put him in touch with doctors from UVM Medical Center: Surgeon Jesse Moore, MD, Medical Oncologist Steven Ades, MD, and Dr. Anker.
“The team at UVM Medical Center was young and gung-ho. They were confident I was the right person for this study,” Patrick recalls.
Historically, patients like Patrick would be enrolled in an often exhausting treatment regimen starting with six weeks of daily radiation treatments (Monday through Friday) given at the same time as chemotherapy, followed by another four months of chemo, and then surgery. At many reputable institutions across the country, this regimen remains the standard of care.
However, explains Dr. Anker, “It’s a lot on a patient. And for people with rectal cancer, this course of treatment leaves them with life-altering changes in their bowel and sexual functions.”
The UVM Medical Center oncology team has a long history of contributing to substantial improvements in the treatment of rectal cancer by offering patients access to clinical trials. Starting in 2015, they joined a study designed at Memorial Sloan Kettering which eliminated surgery from the treatment plan if the tumor went away completely following radiation and chemotherapy. Recently published in 2022 with UVM Medical Center colorectal surgeon Dr. Peter Cataldo as a co-author, more than half of the patients were able to avoid the typical surgery removing their rectum with this approach. If later tests showed that the tumor had grown back, patients were quite successful at having the rectal cancer removed without appearing to lose any ground.
“We’ve seen no detriment to survival rates through this approach,” says Dr. Anker, “and we have found that patients have a quality of life well beyond what we saw before.”
Dr. Anker and his colleagues continued to look for further innovations to minimize the impact of cancer treatment, particularly related to radiation. “We were interested in a shorter course of radiation therapy to get the job done more quickly. It’s a lot of the patient’s life that’s disrupted for cancer care. They have jobs, families, so many other responsibilities.”
Five days of radiation, followed by chemotherapy – and no surgery
In 2019, Dr. Anker was invited to give a presentation at an oncology conference analyzing the latest gastrointestinal cancer research breakthroughs. One study led by Dr. Hyun Kim from Washington University in St. Louis particularly captured his attention. “It involved a shorter course of radiation, followed by chemo, and the outcomes were very encouraging,” he recalls. He approached Dr. Kim after the talk, which led to UVM Medical Center becoming a key partner in the latest clinical trial investigating this approach, which started enrolling patients in 2021.
Patrick completed his one-week radiation course in December 2021. “The appointments were quick and easy. Each one took about 10 minutes. The total time commitment, from walking in, getting changed, doing the radiation, changing back and walking out, was maybe half an hour,” he says.
Patrick reported very few side effects; in fact, he even went skiing a few times on days when he had radiation treatment, and almost all the way through his 16-week chemo treatments, which started up after he completed radiation. However, Patrick notes that his “normal” is not the norm, and Dr. Anker adds that in the shorter course of radiation, each dose is more intense, so some patients do experience stronger side effects in the short term.
So far, 10 patients with cancer at UVM Medical Center have participated in the trial, and Dr. Anker notes that they’ve had several additional spots open up recently for more to enroll. Patients who have a localized rectal tumor with or without spread to lymph nodes but that has not spread to other organs, and who have a motivation to get the treatment done quickly, may be good candidates.
Because this is a relatively small trial where all patients receive the same treatment, more follow-up research is needed. “We believe a good next step would be a randomized trial where we compare the results of this shorter radiation course to those of the longer course. We expect the cancer control rates should be similar, so it will be essential to make quality-of-life outcomes a priority,” Dr. Anker says.
“The goal does not have to be to show one clear winner, but to help patients understand the pros and cons of each option. We can say to them, this is what actual patients have experienced. What makes the most sense for you?”
'I always felt they were in this boat with me'
For Patrick Austin, that approach led him to choose UVM Medical Center for treatment over other well-known institutions. “The UVM Medical Center team was in agreement with me and my goals and how I wanted to deal with this. I always felt they were in this boat with me,” he says.
Now cancer-free, Patrick has been skiing with his son nearly every weekend this winter, a result that makes Dr. Anker smile.
“Patrick’s active lifestyle and great attitude towards loving life and spending time with his family resonated with me,” says Dr. Anker, who has a wife and two children himself, ages 9 and 12. “I wanted him to keep doing those things as much as possible, by not having as obtrusive a cancer plan, and not being so aggressive, in terms of an unnecessary surgery. This research is advancing care to deliver outcomes that weren’t imaginable years ago.”
New Screening Guidelines for Colorectal Cancer
Christopher Anker, MD, a radiation oncologist at the University of Vermont Health Network – UVM Medical Center, and a key member of Patrick Austin’s cancer treatment team, is excited about the early results of their latest clinical trial. However, he emphasizes that the best cancer treatment starts with early screening and detection, and prevention is ideal.
In May 2021, the U.S. Preventative Services Task Force issued new screening recommendations for colorectal cancer. According to that guidance, all men and women should get their first colorectal cancer screening done by age 45 at the latest. (The recommendation used to be age 50.)
And if you have any risk factors such as first degree relatives (parents & siblings, for example) who were diagnosed with colorectal cancer, you should get screened 10 years earlier than your relative’s age at diagnosis or age 45, whichever comes first. While colonoscopy is encouraged because it not only detects cancer but can prevent it by allowing removal of pre-cancerous growths, other options include tests that check for blood in the stool. The best screening test is the one people are willing to do.
“I know I had people in my family with cancer, but this kind of thing was not talked about in my family,” says Patrick, who was diagnosed with colorectal cancer at age 46 after noticing a change in his bowel habits and blood in his stool.
“So now I tell people, if you’re in your 20s and 30s, start thinking about it,” says Patrick, who was able to avoid surgery and a long course of radiation by catching the tumor early. “Age 45 is the new year for colonoscopies. They’re finding cancer earlier and younger. This diagnosis was at age 46. I don’t even want to think what would have happened had I waited four more years.”